A Better World ApplicationPlease PRINT and write in every space (write N/A for Not Applicable) STUDENT APPLICATION INFORMATION: Full Student Name:__________________________________________________________________ (LAST) (FIRST) (MIDDLE) Address:___________________________________________________________________________ (STREET) (CITY) (ZIP) Age:____________ DOB:___/____/_____ M/F:________ Grade:______________ School:__________________________________ Teacher’s Name:______________________ Student ID#:_____________________________ Free/Reduced Lunch : Y/N T-Shirt Size:_______________ Pant Size:________________ Shoe Size:_____________________

PARENT/GUARDIAN CONTACT INFORMATION : Please note , it is very important, that you update ABW staff immediately if an of your contact information changes. This will ensure we are able to remain in communication with you concerning your child; but most importantly, to do so in the event of an emergency. Thank you. Parent/Guardian Name:___________________________________ Relationship to Child:___________ Full Adress:__________________________________________________________________________ Home Phone:______________________________ Cell Phone:____________________________ Place of Employment:______________________________ Work Phone:____________________ Email Address:____________________________________

PERSON(S) AUTHORIZED TO PICK UP CHILD: Person (s) (Age 16 and older) authorized to pick up child, other than parent(s): 1. Name:__________________________________ Phone:_____________________________2. Name:__________________________________ Phone:_____________________________3. Name:__________________________________ Phone:_____________________________

EMERGENCY CONTACT INFORMATION: (We will always contact parents/guardians first, so please provide names and numbers of other people whom we may contact in the event of an emergency, i.e. relatives and close friends or neighbors). Please update A Better World immediately if any of this information should change so we can contact you in case of emergency. Student Applicant Name:_______________________________________________________________ Primary Contact Name:____________________________ Relationship to Student:________________

Check this box if Same as Parent/Guardian Contact Info ⛊Mailing Address: ______________________________________________________________________ Home Phone:__________________________________ Cell: ____________________ Phone:____________________________ Work Phone:___________________________________ Email Address:________________________________________________________________________ Secondary Contact Name:_________________________ Relationship to Student:______________ Mailing Address: ______________________________________________________________________ Home Phone:_______________________________ Cell Phone:____________________________ Work Phone:___________________________________ Email Address:________________________________________________________________________

EMERGENCY CARE INFORMATION: Child’s Physician’s Name:___________________________________

Phone:_______________________ Address:_________________________________ Hospital Preference:__________________________

Insurance Provider: ______________________ Insurance ID#: ______________________________

STUDENT APPLICANT’S HEALTH: (if N/A please write N/A/) Please briefly describe any (medically diagnosed) physical, mental or emotional disabilities or other limitations that the applicant may have: ____________________________________________________________________________________

____________________________________________________________________________________

PRESCRIBED MEDICATION: (if N/A please write N/A/) Please list all current prescribed medications being taken while at After-School and the reason(s). NOTE: These MUST be placed in a zip-lock bag with the student’s full name, included within the bag should be all medications, along with full instructions on their intended use and proper dosage, as well as time(s) of the day to be taken, etc. Name of Medication:_____________________________ Prescription Dosage:_____________________ Dosage Requirements/Freqency:____________________________________________________ Reason for Medication:____________________________________________________________ Name of Medication:_____________________________ Prescription Dosage:_____________________ Dosage Requirements/Freqency:____________________________________________________ Reason for Medication:____________________________________________________________

DIAGNOSED DRUG/MEDICAL/FOOD ALLERGIES: (if N/A please write N/A/) ___________________________________________________________________________________

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DIAGNOSED DIETARY NEEDS: (if N/A please write N/A/) ____________________________________________________________________________________

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APPLICANT’S MEDICAL HISTORY: Please examine the list below and note applicant’s experiences with any of these factors or conditions. If possible, note the year of occurrence and elaborate briefly on the severity or frequency of the condition. Circle One Condition Year(s) Additional Description Yes No Diagnosed Sinus Problems ________ _______________________________ Yes No Diagnosed Headaches ________ _______________________________ Yes No Diagnosed Hearing Problems ________ _______________________________ Yes No Diagnosed Asthma ________ _______________________________ Yes No Diagnosed Seizures ________ _______________________________ Please list any limitations or risks that may result from a seizure:_____________________________________________________________________ Please list known possible triggers, causes or strategies that may be helpful to the staff. _____________________________________________________________________ Other significant diagnosed health concerns: ____________________________________________________________________________

AFFIRMATION OF COMPLETENESS AND ACCURACY OF APPLICATION:

I/We, ________________________________________________________________(parents/guardians name), do hereby Affirm the information provided within the completed application is complete and accurate to the best of my/our knowledge. We give consent for our student applicant __________________________________________ to attend the A Better World After-School Program and to participate in all programs and activities of the A Better World After-School Program. I have read and understand all policies. I further understand that A Better World is not responsible for lost, misplaced, or damaged items.

______________________________________PARENT/GUARDIAN PRINTED NAME ______________________________________STUDENT PRINTED NAME

______________________________________PARENT/GUARDIAN SIGNATURE DATE: ____________

Parent Responsibilities

Application Fee: $25 One-time fee

Weekly Donation Request: We request a $10 donation weekly to ensure your student a spot in our program. If you this is an issue, please schedule a meeting with Mr. Anthony for an alternative plan.

Parent Points: Each parent is required to participate around the program in an effort to help out and take care of the facilities. See below for ways to fulfill this commitment!

You must accrue 8 Parent Points MONTHLY by:

Taking out trash = 1 parent point

Vacuuming hallways = 2 parent points

Vacuuming Sanctuary = 2 parent points

Cleaning windows = 2 parent points

Parent Meetings = 2 points

Kitchen Clean up = 2 points

Help Serve Dinner (4:30-5:00) -2 points

Attending Wednesday bible study = 3 parent points

Attending Sunday Church service = 3 parent points

Family Fun Night takes place on the first Thursday of every month and is REQUIRED. Family Fun Night goes from 6:00-8:30 and includes dinner for the whole family, games for the kids and a guest speaker for the parents!

RELEASE OF LIABILITYA Better World

READ THIS ENTIRE DOCUMENT CAREFULLY BEFORE SIGNING AS IT AFFECTS YOUR LEGAL

RIGHTS. THIS IS A RELEASE, WAIVER OF LIABILITY, AND PROMISE NOT TO SUE FOR INJURIES, DAMAGES OR LOSS ARISING FROM THE ACTIVITIES DESCRIBED BELOW.

A Better World Inc. is a non-profit organization that reaches out to children and their families in the Ashley Park Community and the surrounding area to offer afterschool care, classes and training which will assist them in many areas of their life. Your child being provided the opportunity to use or occupy, or to benefit from the use and occupancy, of the A Better World premises located at 4527 Freedom Drive, Charlotte, NC 28208 (sometimes hereafter referred to as the “Center). The activities are designed to allow the Participant to broaden their understanding of various Christian values, socioeconomic differences, ethnic and racial diversity, cultural appreciation, team building, character development and/or enrichment opportunities. Participants may be exposed to physical and psychological risks through elements of nature, travel by car or van or walking or other conveyance, and direct contact with people from various backgrounds. This may also include damage or loss of personal property. From time to time volunteers as well as employees of A Better World will be transporting your child to various activities with your permission including without limitation movies, ballgames, parks, museums and other outings. Prior to each such outing, you will be required to sign a permission slip. Each permission slip will be subject to the terms of this Release. If we do not have a signed release for your child, your child cannot be permitted to participate in the activities of A Better World or be transported to additional activities off premises. Upon execution of this Release, it will stay in effect until you specifically revoke it in writing. We make every endeavor to determine that anyone engaged in transporting children have a valid driver’s license and is not impaired. However, we cannot do extensive testing nor repeated reference searches. In order for you to agree that your child be permitted to use the Center and be transported by volunteers or employees to outside activities provided from time to time, you must read and agree to the complete terms and conditions of this Release which among other things contain Release and Waiver of Liability, Assumption of Risk and Indemnity provisions. The complete terms and conditions are set forth below. Your signature below also gives permission and accepts financial responsibility as well for first aid treatment and/or professional medical attention for your child as needed. It also serves as permission for photographing of yourself and your child during the activities of A Better World and use of those pictures or videos by A Better World. RELEASE AND WAIVER OF LIABILITY. In consideration for my child’s use of, occupancy of or other benefit from the Center and all related activities including, but not limited to, transportation to and from the Center and all other activities typically associated with activities of the Center, being transported or otherwise involved in various authorized activities with any Volunteer of the Center (collectively, “Covered Activities”), I, on my own behalf and on behalf of any minor child participating in Covered Activities for whom I am a parent or guardian or otherwise responsible, and for my and their heirs, agents, personal representatives and assigns, in exchange for the good and valuable consideration set forth herein, do hereby release, acquit, satisfy, forever discharge and promise not to sue the Center, its landlord and the property owner, Christ Resurrection Church, any Volunteer and all of their officers, directors, members,

employees, agents, respective heirs, legal representatives, successors and assigns, as well as the insurers of any of them and any other persons acting by, through, under or in concert with any of the above persons or entities (collectively, “Released Parties”), from any and all claims, actions, causes of action, demands or suits of any kind, judgments, damages, losses, expenses or other liabilities, whether based in equity or law, express or implied, including court costs, expenses and attorneys’ fees, I or my child have or may have against the Released Parties related to or arising out of the Covered Activities, including but not limited to, any alleged personal or bodily injury, disfigurement, pain and suffering, wrongful death, property damage, financial loss or any other damages, whether resulting from the negligence, gross negligence, intentional acts or other fault, either active or passive, of any of the Released Parties, or from any other cause. I further acknowledge that statutes may exist that render full and void releases and discharges of any claims, rights, demands, liabilities, actions and causes of action which are unknown to the releasing or discharging party at the time of execution of the release and discharge, or which otherwise may limit the effectiveness of releases. I hereby expressly waive, surrender and agree to forego any protection to which it would otherwise be entitled by virtue of the existence of any such statute in any jurisdiction. ASSUMPTION OF RISK. I understand that accidents could occur in any of the Covered Activities being provided by the Center and any Volunteer. I further acknowledge that many of the risks and dangers cannot be foreseen and are inherent in the Covered Activities. I voluntarily and freely choose to assume on my behalf and that of my minor child who is the participant all risks and dangers associated with the Covered Activities with a clear and complete understanding that those risks and dangers may include, but are not limited to, personal or bodily injury, disfigurement, pain and suffering, wrongful death, property damage, financial loss and any other damages arising out of the accident or injury or otherwise. I also understand that participation in the Covered Activities is not required, but is solely a voluntary activity undertaken by my own choosing. INDEMNITY. I agree to indemnify and hold harmless the Released Parties from any and all claims, actions, causes of action, demands, judgments or liabilities of any kind. Including court costs, expenses and attorneys’ fees, whether express or implied, of every kind, nature and description whatsoever related to or arising out of the Covered Activities, including but not limited to, any alleged personal or bodily injury, disfigurement, pain and suffering, wrongful death, property damage, financial loss and any other damages, whether resulting from the negligence, gross negligence, other fault, either active or passive, of any of the Released Parties, or from any other cause. ATTORNEY’S FEES AND COSTS. In the event of any litigation, including any appeals, arising from or relating to the enforcement, scope, meaning, interpretation, performance or non-performance of or under this Release, the prevailing party therein shall be entitled to recover from the non-prevailing party all reasonable attorneys’ fees, paralegal fees, court costs and other costs incurred in connection therewith, including any appeal. VENUE AND CHOICE OF LAW. Any legal proceeding of any nature brought by any party against the other to enforce or interpret any right or obligation under this Release or the Covered Activities shall be brought solely and exclusively in Mecklenburg County, North Carolina, before the appropriate Court of competent jurisdiction. The parties hereto agree that this Release, and any dispute arising hereunder, or otherwise related to the Covered Activities shall be governed by and interpreted according to the substantive laws of the State of North Carolina without regard to its choice of law or conflicts of laws principles.

SEVERABILITY. In the event that any provision of this Release is held void or otherwise invalid, it is agreed that the remaining provisions shall continue in full legal force and effect. WAIVER OF JURY TRIAL. AS A MATERIAL INDUCEMENT FOR PROVIDING THE COVERED ACTIVITIES, THE UNDERSIGNED HEREBY KNOWINGLY, VOLUNTARILY, INTENTIONALLY AND IRREVOCABLY WAIVES ALL RIGHTS TO A TRIAL BY JURY OF ANY ISSUES SO TRIABLE. READING NOTICE. READ THIS ENTIRE DOCUMENT CAREFULLY BEFORE SIGNING AS IT AFFECTS YOUR LEGAL RIGHTS. THIS IS A RELEASE, WAIVER OF LIABILITY, AND PROMISE NOT TO SUE FOR INJURIES, DEATH, DAMAGES OR LOSSES ARISING FROM THE COVERED ACTIVITIES DESCRIBED ABOVE. CONFIRMATION. I HAVE CAREFULLY READ THIS RELEASE, I FULLY UNDERSTAND ITS CONTENTS AND AGREE TO ALL OF THE TERMS AND CONDITIONS SET FORTH ABOVE, AND HAVE SIGNED IT OF MY OWN FREE WILL THIS _____________ DAY OF ________________, 20_____.

Parent/Guardian Signature: ___________________